Diabetes Mellitus
davejaymanriquez
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Jan 01, 2009
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About This Presentation
pathophysiology and definition of diabetes mellitus.
Slide Content
A thorough discussionA thorough discussion
about the Assessment and about the Assessment and
Management of Patients with Management of Patients with
Diabetes MellitusDiabetes Mellitus
Prepared by: Dave Jay S. Manriquez RN.Prepared by: Dave Jay S. Manriquez RN.
about the Assessment and about the Assessment and
Management of Patients with Management of Patients with
Diabetes MellitusDiabetes Mellitus
Prepared by: Dave Jay S. Manriquez RN.Prepared by: Dave Jay S. Manriquez RN.
Diabetes MellitusDiabetes Mellitus
A heterogeneous group of disorders A heterogeneous group of disorders
characterized by an elevation in the characterized by an elevation in the
level of glucose in the blood.level of glucose in the blood.
In Diabetes there may be a decrease in In Diabetes there may be a decrease in
the body’s ability to respond to insulin the body’s ability to respond to insulin
and/or a decrease or absence of insulin and/or a decrease or absence of insulin
produced by the pancreas.produced by the pancreas.
A heterogeneous group of disorders A heterogeneous group of disorders
characterized by an elevation in the characterized by an elevation in the
level of glucose in the blood.level of glucose in the blood.
In Diabetes there may be a decrease in In Diabetes there may be a decrease in
the body’s ability to respond to insulin the body’s ability to respond to insulin
and/or a decrease or absence of insulin and/or a decrease or absence of insulin
produced by the pancreas.produced by the pancreas.
Diabetes MellitusDiabetes Mellitus
The resulting hyperglycemia may lead to The resulting hyperglycemia may lead to
acute metabolic complications such as acute metabolic complications such as
diabetic ketoacidosis and hyperosmolar diabetic ketoacidosis and hyperosmolar
nonketotic syndrome. nonketotic syndrome.
Long term hyperglycemia may contribute Long term hyperglycemia may contribute
to chronic microvascular complications, to chronic microvascular complications,
neuropathic complications, and neuropathic complications, and
macrovascular diseases.macrovascular diseases.
The resulting hyperglycemia may lead to The resulting hyperglycemia may lead to
acute metabolic complications such as acute metabolic complications such as
diabetic ketoacidosis and hyperosmolar diabetic ketoacidosis and hyperosmolar
nonketotic syndrome. nonketotic syndrome.
Long term hyperglycemia may contribute Long term hyperglycemia may contribute
to chronic microvascular complications, to chronic microvascular complications,
neuropathic complications, and neuropathic complications, and
macrovascular diseases.macrovascular diseases.
How will you know if you How will you know if you
are a diabetic? are a diabetic?
If you urinate frequently, experience excessive If you urinate frequently, experience excessive
thirst and unexplained weight loss. thirst and unexplained weight loss.
If your casual blood sugar (plasma glucose) If your casual blood sugar (plasma glucose)
level is higher than 200mg/dl. level is higher than 200mg/dl.
If you have fasting plasma glucose level of not If you have fasting plasma glucose level of not
more than 126mg/dl. more than 126mg/dl.
are a diabetic? are a diabetic?
If you urinate frequently, experience excessive If you urinate frequently, experience excessive
thirst and unexplained weight loss. thirst and unexplained weight loss.
If your casual blood sugar (plasma glucose) If your casual blood sugar (plasma glucose)
level is higher than 200mg/dl. level is higher than 200mg/dl.
If you have fasting plasma glucose level of not If you have fasting plasma glucose level of not
more than 126mg/dl. more than 126mg/dl.
Who are at risk of diabetes?Who are at risk of diabetes?
children of diabetics children of diabetics
obese people obese people
people with hypertension people with hypertension
people with high cholesterol levelspeople with high cholesterol levels
people with sedentary lifestyles people with sedentary lifestyles
children of diabetics children of diabetics
obese people obese people
people with hypertension people with hypertension
people with high cholesterol levelspeople with high cholesterol levels
people with sedentary lifestyles people with sedentary lifestyles
Types of DiabetesTypes of Diabetes
Type 1 : Insulin-dependent diabetes mellitusType 1 : Insulin-dependent diabetes mellitus
Type 2 : Non-insulin-dependent diabetes Type 2 : Non-insulin-dependent diabetes
mellitusmellitus
Diabetes mellitus associated with other Diabetes mellitus associated with other
conditions or syndromesconditions or syndromes
Gestational diabetes mellitusGestational diabetes mellitus
Type 1 : Insulin-dependent diabetes mellitusType 1 : Insulin-dependent diabetes mellitus
Type 2 : Non-insulin-dependent diabetes Type 2 : Non-insulin-dependent diabetes
mellitusmellitus
Diabetes mellitus associated with other Diabetes mellitus associated with other
conditions or syndromesconditions or syndromes
Gestational diabetes mellitusGestational diabetes mellitus
Types of DiabetesTypes of Diabetes
Type 1: About 5% to 10% of people with Diabetes. A Type 1: About 5% to 10% of people with Diabetes. A
form of diabetes wherein there is inadequate amounts of form of diabetes wherein there is inadequate amounts of
insulin are produced by the pancreas, resulting in the insulin are produced by the pancreas, resulting in the
need for insulin injections to control the blood glucose. need for insulin injections to control the blood glucose.
It is also characterized by sudden onset usually before It is also characterized by sudden onset usually before
the age of 30 years.the age of 30 years.
Type 2: About 90% to 95% of people with Diabetes. Type 2: About 90% to 95% of people with Diabetes.
Cause by a decrease in the sensitivity of the cells to Cause by a decrease in the sensitivity of the cells to
insulin and the decrease in the amount of insulin insulin and the decrease in the amount of insulin
produced. It can be treated with diet, oral hypoglycemic produced. It can be treated with diet, oral hypoglycemic
agents and insulin injections. It occurs most frequently agents and insulin injections. It occurs most frequently
in people who are over 30 years of age and obese. in people who are over 30 years of age and obese.
Type 1: About 5% to 10% of people with Diabetes. A Type 1: About 5% to 10% of people with Diabetes. A
form of diabetes wherein there is inadequate amounts of form of diabetes wherein there is inadequate amounts of
insulin are produced by the pancreas, resulting in the insulin are produced by the pancreas, resulting in the
need for insulin injections to control the blood glucose. need for insulin injections to control the blood glucose.
It is also characterized by sudden onset usually before It is also characterized by sudden onset usually before
the age of 30 years.the age of 30 years.
Type 2: About 90% to 95% of people with Diabetes. Type 2: About 90% to 95% of people with Diabetes.
Cause by a decrease in the sensitivity of the cells to Cause by a decrease in the sensitivity of the cells to
insulin and the decrease in the amount of insulin insulin and the decrease in the amount of insulin
produced. It can be treated with diet, oral hypoglycemic produced. It can be treated with diet, oral hypoglycemic
agents and insulin injections. It occurs most frequently agents and insulin injections. It occurs most frequently
in people who are over 30 years of age and obese. in people who are over 30 years of age and obese.
Learn More about Learn More about
Diabetes Mellitus with this Diabetes Mellitus with this
Song Rap….Song Rap….
Diabetes Mellitus with this Diabetes Mellitus with this
Song Rap….Song Rap….
EpidemiologyEpidemiology
Diabetes is the third leading cause of death by Diabetes is the third leading cause of death by
disease, mostly because of the high rate of coronary disease, mostly because of the high rate of coronary
artery disease among people with diabetes.artery disease among people with diabetes.
Diabetes is the leading cause of new blindness (among Diabetes is the leading cause of new blindness (among
25 to 74 years old) and nontraumatic amputations in 25 to 74 years old) and nontraumatic amputations in
the United States.the United States.
25% of patients on dialysis have diabetes.25% of patients on dialysis have diabetes.
Hispanic, black, and some Native American populations Hispanic, black, and some Native American populations
have a higher rate of diabetes than the white have a higher rate of diabetes than the white
populations.populations.
Diabetes is the third leading cause of death by Diabetes is the third leading cause of death by
disease, mostly because of the high rate of coronary disease, mostly because of the high rate of coronary
artery disease among people with diabetes.artery disease among people with diabetes.
Diabetes is the leading cause of new blindness (among Diabetes is the leading cause of new blindness (among
25 to 74 years old) and nontraumatic amputations in 25 to 74 years old) and nontraumatic amputations in
the United States.the United States.
25% of patients on dialysis have diabetes.25% of patients on dialysis have diabetes.
Hispanic, black, and some Native American populations Hispanic, black, and some Native American populations
have a higher rate of diabetes than the white have a higher rate of diabetes than the white
populations.populations.
EpidemiologyEpidemiology
Diabetes in 2007Diabetes in 2007
• 23.6 million — Number of Americans who had 23.6 million — Number of Americans who had
diabetes diabetes
•12.2 million — Number of Americans 60 and 12.2 million — Number of Americans 60 and
older with diabetes older with diabetes
•5.7 million — Number of undiagnosed cases of 5.7 million — Number of undiagnosed cases of
diabetes diabetes
•1.6 million — Number of new cases of diabetes 1.6 million — Number of new cases of diabetes
in adultsin adults
•186,300 — Number of people younger than 20 186,300 — Number of people younger than 20
with diabeteswith diabetes
•$174 billion — Economic cost of diabetes$174 billion — Economic cost of diabetes
Source: American Diabetes AssociationSource: American Diabetes Association
Diabetes in 2007Diabetes in 2007
• 23.6 million — Number of Americans who had 23.6 million — Number of Americans who had
diabetes diabetes
•12.2 million — Number of Americans 60 and 12.2 million — Number of Americans 60 and
older with diabetes older with diabetes
•5.7 million — Number of undiagnosed cases of 5.7 million — Number of undiagnosed cases of
diabetes diabetes
•1.6 million — Number of new cases of diabetes 1.6 million — Number of new cases of diabetes
in adultsin adults
•186,300 — Number of people younger than 20 186,300 — Number of people younger than 20
with diabeteswith diabetes
•$174 billion — Economic cost of diabetes$174 billion — Economic cost of diabetes
Source: American Diabetes AssociationSource: American Diabetes Association
EpidemiologyEpidemiology
There are 2.8 million Filipinos who were
diagnosed with diabetes.
From 1993 to 1997, 2.1 percent of the
deaths recorded are due to diabetes and
annually the cases of diabetes continue to
increase by 2.5 percent.
There are 2.8 million Filipinos who were
diagnosed with diabetes.
From 1993 to 1997, 2.1 percent of the
deaths recorded are due to diabetes and
annually the cases of diabetes continue to
increase by 2.5 percent.
What is an Insulin?What is an Insulin?
Secreted by the beta cells, which are one of four types Secreted by the beta cells, which are one of four types
of cells in the islets of langerhans in the pancreas. It is of cells in the islets of langerhans in the pancreas. It is
considered to be an anabolic, or storage, hormone. When considered to be an anabolic, or storage, hormone. When
a meal is eaten, insulin secretion increases and moves a meal is eaten, insulin secretion increases and moves
glucose from the circulation into muscle, liver, and fat glucose from the circulation into muscle, liver, and fat
cells.cells.
During “fasting periods” (between meals and overnight) During “fasting periods” (between meals and overnight)
there is a lower production of insulin accompanied by an there is a lower production of insulin accompanied by an
increased release of another pancreatic hormone the increased release of another pancreatic hormone the
glucagon. The net effect of the balance between insulin glucagon. The net effect of the balance between insulin
and glucagon levels is to maintain a constant level of and glucagon levels is to maintain a constant level of
glucose in the blood through release of glucose from the glucose in the blood through release of glucose from the
liver.liver.
Secreted by the beta cells, which are one of four types Secreted by the beta cells, which are one of four types
of cells in the islets of langerhans in the pancreas. It is of cells in the islets of langerhans in the pancreas. It is
considered to be an anabolic, or storage, hormone. When considered to be an anabolic, or storage, hormone. When
a meal is eaten, insulin secretion increases and moves a meal is eaten, insulin secretion increases and moves
glucose from the circulation into muscle, liver, and fat glucose from the circulation into muscle, liver, and fat
cells.cells.
During “fasting periods” (between meals and overnight) During “fasting periods” (between meals and overnight)
there is a lower production of insulin accompanied by an there is a lower production of insulin accompanied by an
increased release of another pancreatic hormone the increased release of another pancreatic hormone the
glucagon. The net effect of the balance between insulin glucagon. The net effect of the balance between insulin
and glucagon levels is to maintain a constant level of and glucagon levels is to maintain a constant level of
glucose in the blood through release of glucose from the glucose in the blood through release of glucose from the
liver.liver.
The Pancreas….The Pancreas….
Learn more about pancreas Learn more about pancreas
with this video with this video
presentation….presentation….
with this video with this video
presentation….presentation….
Insulin Functions….Insulin Functions….
Stimulates storage of glucose in the liver and Stimulates storage of glucose in the liver and
muscle (in the form of glycogen).muscle (in the form of glycogen).
Enhances storage of dietary fat in adipose Enhances storage of dietary fat in adipose
tissue.tissue.
Accelerates transport of amino acids (derived Accelerates transport of amino acids (derived
from dietary protein) into the cells.from dietary protein) into the cells.
Insulin also inhibits the breakdown of stored Insulin also inhibits the breakdown of stored
glucose, protein, and fat. glucose, protein, and fat.
Stimulates storage of glucose in the liver and Stimulates storage of glucose in the liver and
muscle (in the form of glycogen).muscle (in the form of glycogen).
Enhances storage of dietary fat in adipose Enhances storage of dietary fat in adipose
tissue.tissue.
Accelerates transport of amino acids (derived Accelerates transport of amino acids (derived
from dietary protein) into the cells.from dietary protein) into the cells.
Insulin also inhibits the breakdown of stored Insulin also inhibits the breakdown of stored
glucose, protein, and fat. glucose, protein, and fat.
Learn More About Insulin Learn More About Insulin
with this video with this video
presentation….presentation….
with this video with this video
presentation….presentation….
Classification of Diabetes Mellitus and Related Glucose Classification of Diabetes Mellitus and Related Glucose
IntoleranceIntolerance
Etiology includes obesity, Etiology includes obesity,
heredity, and environmental heredity, and environmental
factorsfactors
Oral hypoglycemic agents may Oral hypoglycemic agents may
improve blood glucose levelimprove blood glucose level
Acute complication: Acute complication:
hyperosmolar nonketotic hyperosmolar nonketotic
syndromesyndrome
Adult onset diabetesAdult onset diabetes
Maturity onset diabetesMaturity onset diabetes
Ketosis resistant diabetesKetosis resistant diabetes
Stable diabetesStable diabetes
Type 2: Non-insulin-Type 2: Non-insulin-
dependent diabetes (NIDDM)dependent diabetes (NIDDM)
Etiology includes genetic, Etiology includes genetic,
immunologic, and or immunologic, and or
environmental factorsenvironmental factors
Need insulin to preserve lifeNeed insulin to preserve life
Acute complication of Acute complication of
hyperglycemia: diabetic hyperglycemia: diabetic
ketoacidosisketoacidosis
Juvenile diabetesJuvenile diabetes
Ketosis prone diabetesKetosis prone diabetes
Brittle diabetesBrittle diabetes
Type 1: Insulin – dependent Type 1: Insulin – dependent
diabetes mellitus (IDDM)diabetes mellitus (IDDM)
Clinical CharacteristicsClinical CharacteristicsPrevious ClassificationsPrevious ClassificationsCurrent ClassificationCurrent Classification
IntoleranceIntolerance
Etiology includes obesity, Etiology includes obesity,
heredity, and environmental heredity, and environmental
factorsfactors
Oral hypoglycemic agents may Oral hypoglycemic agents may
improve blood glucose levelimprove blood glucose level
Acute complication: Acute complication:
hyperosmolar nonketotic hyperosmolar nonketotic
syndromesyndrome
Adult onset diabetesAdult onset diabetes
Maturity onset diabetesMaturity onset diabetes
Ketosis resistant diabetesKetosis resistant diabetes
Stable diabetesStable diabetes
Type 2: Non-insulin-Type 2: Non-insulin-
dependent diabetes (NIDDM)dependent diabetes (NIDDM)
Etiology includes genetic, Etiology includes genetic,
immunologic, and or immunologic, and or
environmental factorsenvironmental factors
Need insulin to preserve lifeNeed insulin to preserve life
Acute complication of Acute complication of
hyperglycemia: diabetic hyperglycemia: diabetic
ketoacidosisketoacidosis
Juvenile diabetesJuvenile diabetes
Ketosis prone diabetesKetosis prone diabetes
Brittle diabetesBrittle diabetes
Type 1: Insulin – dependent Type 1: Insulin – dependent
diabetes mellitus (IDDM)diabetes mellitus (IDDM)
Clinical CharacteristicsClinical CharacteristicsPrevious ClassificationsPrevious ClassificationsCurrent ClassificationCurrent Classification
Classification of Diabetes Mellitus and Related Glucose Classification of Diabetes Mellitus and Related Glucose
IntoleranceIntolerance
Onset during pregnanacy 2Onset during pregnanacy 2
ndnd
and 3and 3
rdrd
trimester trimester
Due to hormones secreted by Due to hormones secreted by
placenta , which inhibit the placenta , which inhibit the
action of insulinaction of insulin
Risk factor: obesity, age over Risk factor: obesity, age over
30, family hx of diabetes, 30, family hx of diabetes,
previous large babies (over previous large babies (over
9lb)9lb)
Gestational diabetesGestational diabetesGestational diabetesGestational diabetes
Accompanied by conditions Accompanied by conditions
known or suspected to cause known or suspected to cause
the disease: pancreatic the disease: pancreatic
diseases; hormonal diseases; hormonal
abnormalities; drug such as abnormalities; drug such as
glucocorticoids and estrogen glucocorticoids and estrogen
containing preparationscontaining preparations
Secondary diabetesSecondary diabetesDiabetes mellitus associated Diabetes mellitus associated
with other conditions or with other conditions or
syndromessyndromes
Clinical CharacteristicsClinical CharacteristicsPrevious ClassificationsPrevious ClassificationsCurrent ClassificationCurrent Classification
IntoleranceIntolerance
Onset during pregnanacy 2Onset during pregnanacy 2
ndnd
and 3and 3
rdrd
trimester trimester
Due to hormones secreted by Due to hormones secreted by
placenta , which inhibit the placenta , which inhibit the
action of insulinaction of insulin
Risk factor: obesity, age over Risk factor: obesity, age over
30, family hx of diabetes, 30, family hx of diabetes,
previous large babies (over previous large babies (over
9lb)9lb)
Gestational diabetesGestational diabetesGestational diabetesGestational diabetes
Accompanied by conditions Accompanied by conditions
known or suspected to cause known or suspected to cause
the disease: pancreatic the disease: pancreatic
diseases; hormonal diseases; hormonal
abnormalities; drug such as abnormalities; drug such as
glucocorticoids and estrogen glucocorticoids and estrogen
containing preparationscontaining preparations
Secondary diabetesSecondary diabetesDiabetes mellitus associated Diabetes mellitus associated
with other conditions or with other conditions or
syndromessyndromes
Clinical CharacteristicsClinical CharacteristicsPrevious ClassificationsPrevious ClassificationsCurrent ClassificationCurrent Classification
Classification of Diabetes Mellitus and Related Glucose Classification of Diabetes Mellitus and Related Glucose
IntoleranceIntolerance
Previous history of Previous history of
hyperglycemia (eg. Pregnancy hyperglycemia (eg. Pregnancy
or illness)or illness)
No hx of glucose intolerance No hx of glucose intolerance
but increase risk of diabetes but increase risk of diabetes
due to family hx, obese, racedue to family hx, obese, race
Latent diabetesLatent diabetes
PrediabetesPrediabetes
Previous abnormality of Previous abnormality of
glucose toleranceglucose tolerance
Potential abnormality of Potential abnormality of
glucose toleranceglucose tolerance
Blood glucose levels between Blood glucose levels between
normal and that of diabetes normal and that of diabetes
25% eventually develop 25% eventually develop
diabetesdiabetes
May be obese or nonobese; May be obese or nonobese;
obese should reduce weight obese should reduce weight
Borderline diabetesBorderline diabetes
Chemical diabetesChemical diabetes
Subclinical diabetesSubclinical diabetes
Asymptomatic diabetesAsymptomatic diabetes
Impaired glucose intoleranceImpaired glucose intolerance
Clinical CharacteristicsClinical CharacteristicsPrevious ClassificationsPrevious ClassificationsCurrent ClassificationCurrent Classification
IntoleranceIntolerance
Previous history of Previous history of
hyperglycemia (eg. Pregnancy hyperglycemia (eg. Pregnancy
or illness)or illness)
No hx of glucose intolerance No hx of glucose intolerance
but increase risk of diabetes but increase risk of diabetes
due to family hx, obese, racedue to family hx, obese, race
Latent diabetesLatent diabetes
PrediabetesPrediabetes
Previous abnormality of Previous abnormality of
glucose toleranceglucose tolerance
Potential abnormality of Potential abnormality of
glucose toleranceglucose tolerance
Blood glucose levels between Blood glucose levels between
normal and that of diabetes normal and that of diabetes
25% eventually develop 25% eventually develop
diabetesdiabetes
May be obese or nonobese; May be obese or nonobese;
obese should reduce weight obese should reduce weight
Borderline diabetesBorderline diabetes
Chemical diabetesChemical diabetes
Subclinical diabetesSubclinical diabetes
Asymptomatic diabetesAsymptomatic diabetes
Impaired glucose intoleranceImpaired glucose intolerance
Clinical CharacteristicsClinical CharacteristicsPrevious ClassificationsPrevious ClassificationsCurrent ClassificationCurrent Classification
Etiology of Type 1 DiabetesEtiology of Type 1 Diabetes
Combination of Genetic, Immunologic, and possibly Combination of Genetic, Immunologic, and possibly
Environmental factors contribute to beta cells Environmental factors contribute to beta cells
destruction.destruction.
Genetic Genetic – People do not inherit type 1 DM itself; rather, they – People do not inherit type 1 DM itself; rather, they
inherit a genetic predisposition, or tendency, toward inherit a genetic predisposition, or tendency, toward
developing type 1 DM. This genetic tendency has been found developing type 1 DM. This genetic tendency has been found
in people with certain HLA (human leukocyte antigen) types. in people with certain HLA (human leukocyte antigen) types.
95% of patients with type 1 diabetes exhibit specific HLA 95% of patients with type 1 diabetes exhibit specific HLA
types (DR3 or DR4). The risk of developing type 1 DM is types (DR3 or DR4). The risk of developing type 1 DM is
increased 3-5 times in people who have one of these two increased 3-5 times in people who have one of these two
HLA types.HLA types.
Combination of Genetic, Immunologic, and possibly Combination of Genetic, Immunologic, and possibly
Environmental factors contribute to beta cells Environmental factors contribute to beta cells
destruction.destruction.
Genetic Genetic – People do not inherit type 1 DM itself; rather, they – People do not inherit type 1 DM itself; rather, they
inherit a genetic predisposition, or tendency, toward inherit a genetic predisposition, or tendency, toward
developing type 1 DM. This genetic tendency has been found developing type 1 DM. This genetic tendency has been found
in people with certain HLA (human leukocyte antigen) types. in people with certain HLA (human leukocyte antigen) types.
95% of patients with type 1 diabetes exhibit specific HLA 95% of patients with type 1 diabetes exhibit specific HLA
types (DR3 or DR4). The risk of developing type 1 DM is types (DR3 or DR4). The risk of developing type 1 DM is
increased 3-5 times in people who have one of these two increased 3-5 times in people who have one of these two
HLA types.HLA types.
Etiology of Type 1 DiabetesEtiology of Type 1 Diabetes
Immunologic Immunologic – Abnormal response in which antibodies – Abnormal response in which antibodies
are directed against normal tissues as if they are are directed against normal tissues as if they are
foreign. Auto antibodies against islet cells and foreign. Auto antibodies against islet cells and
against endogenous (internal) insulin have been against endogenous (internal) insulin have been
detected in people at the time of diagnosis.detected in people at the time of diagnosis.
EnvironmentalEnvironmental – Certain viruses or toxins may – Certain viruses or toxins may
precipitate the autoimmune process that leads to precipitate the autoimmune process that leads to
beta cell destruction.beta cell destruction.
Immunologic Immunologic – Abnormal response in which antibodies – Abnormal response in which antibodies
are directed against normal tissues as if they are are directed against normal tissues as if they are
foreign. Auto antibodies against islet cells and foreign. Auto antibodies against islet cells and
against endogenous (internal) insulin have been against endogenous (internal) insulin have been
detected in people at the time of diagnosis.detected in people at the time of diagnosis.
EnvironmentalEnvironmental – Certain viruses or toxins may – Certain viruses or toxins may
precipitate the autoimmune process that leads to precipitate the autoimmune process that leads to
beta cell destruction.beta cell destruction.
Learn more about Diabetes Learn more about Diabetes
Mellitus Type 1 with this Mellitus Type 1 with this
video presentation….video presentation….
Mellitus Type 1 with this Mellitus Type 1 with this
video presentation….video presentation….
Etiology of Type 2 DiabetesEtiology of Type 2 Diabetes
The exact mechanisms that lead to insulin resistance and impaired The exact mechanisms that lead to insulin resistance and impaired
insulin secretion in type 2 are still unknown at this time. But insulin secretion in type 2 are still unknown at this time. But
they say Genetic factor play an important role in developing they say Genetic factor play an important role in developing
insulin resistance.insulin resistance.
There are certain risk factors:There are certain risk factors:
Age (insulin resistance tends to occur with age over 65)Age (insulin resistance tends to occur with age over 65)
ObesityObesity
Family historyFamily history
Ethnic group (Hispanic and American Indians)Ethnic group (Hispanic and American Indians)
The exact mechanisms that lead to insulin resistance and impaired The exact mechanisms that lead to insulin resistance and impaired
insulin secretion in type 2 are still unknown at this time. But insulin secretion in type 2 are still unknown at this time. But
they say Genetic factor play an important role in developing they say Genetic factor play an important role in developing
insulin resistance.insulin resistance.
There are certain risk factors:There are certain risk factors:
Age (insulin resistance tends to occur with age over 65)Age (insulin resistance tends to occur with age over 65)
ObesityObesity
Family historyFamily history
Ethnic group (Hispanic and American Indians)Ethnic group (Hispanic and American Indians)
LearnLearn moremore about Diabetes about Diabetes
Mellitus Type 2 with this Mellitus Type 2 with this
video presentations….video presentations….
Mellitus Type 2 with this Mellitus Type 2 with this
video presentations….video presentations….
World Health Organization Diagnostic Criteria for World Health Organization Diagnostic Criteria for
Diabetes Mellitus in AdultsDiabetes Mellitus in Adults
On at least two occasions:On at least two occasions:
3.3.Random plasma glucose > 200mg/dlRandom plasma glucose > 200mg/dl
5.5.Fasting plasma glucose > 140mg/dlFasting plasma glucose > 140mg/dl
7.7.2-hour sample during 75g OGTT (Oral Glucose Tolerance Test) 2-hour sample during 75g OGTT (Oral Glucose Tolerance Test)
> 200mg/dl> 200mg/dl
OGTT OGTT – The patient ingest high CHO (150-300g) meals for 3 days – The patient ingest high CHO (150-300g) meals for 3 days
preceding the test. After an overnight fast, a blood sample is preceding the test. After an overnight fast, a blood sample is
drawn. Then a 75g CHO load, usually in the form of carbonated drawn. Then a 75g CHO load, usually in the form of carbonated
sugar beverage (Glucola), is given to patient. The patient is sugar beverage (Glucola), is given to patient. The patient is
instructed to sit quietly, avoid exercise, smoking, coffee, and instructed to sit quietly, avoid exercise, smoking, coffee, and
any other oral intake except water. WHO recommends that any other oral intake except water. WHO recommends that
after 2 hours a blood sample is drawn after glucose ingestion. after 2 hours a blood sample is drawn after glucose ingestion.
Diabetes Mellitus in AdultsDiabetes Mellitus in Adults
On at least two occasions:On at least two occasions:
3.3.Random plasma glucose > 200mg/dlRandom plasma glucose > 200mg/dl
5.5.Fasting plasma glucose > 140mg/dlFasting plasma glucose > 140mg/dl
7.7.2-hour sample during 75g OGTT (Oral Glucose Tolerance Test) 2-hour sample during 75g OGTT (Oral Glucose Tolerance Test)
> 200mg/dl> 200mg/dl
OGTT OGTT – The patient ingest high CHO (150-300g) meals for 3 days – The patient ingest high CHO (150-300g) meals for 3 days
preceding the test. After an overnight fast, a blood sample is preceding the test. After an overnight fast, a blood sample is
drawn. Then a 75g CHO load, usually in the form of carbonated drawn. Then a 75g CHO load, usually in the form of carbonated
sugar beverage (Glucola), is given to patient. The patient is sugar beverage (Glucola), is given to patient. The patient is
instructed to sit quietly, avoid exercise, smoking, coffee, and instructed to sit quietly, avoid exercise, smoking, coffee, and
any other oral intake except water. WHO recommends that any other oral intake except water. WHO recommends that
after 2 hours a blood sample is drawn after glucose ingestion. after 2 hours a blood sample is drawn after glucose ingestion.
Learn more about Blood Learn more about Blood
Glucose Monitoring with this Glucose Monitoring with this
video presentation….video presentation….
Glucose Monitoring with this Glucose Monitoring with this
video presentation….video presentation….
Complications of DiabetesComplications of Diabetes
Acute Complications: result from an imbalance in Acute Complications: result from an imbalance in
the treatment regimen.the treatment regimen.
Hypoglycemia (low blood sugar), which is also Hypoglycemia (low blood sugar), which is also
called insulin reaction or insulin shock.called insulin reaction or insulin shock.
Hyperglycemia (high blood sugar), which, if Hyperglycemia (high blood sugar), which, if
uncontrolled, may lead to diabetic ketoacidosis uncontrolled, may lead to diabetic ketoacidosis
(DKA) in type 1 diabetes or hyperosmolar (DKA) in type 1 diabetes or hyperosmolar
nonketotic syndrome (HNKS) in type 2 nonketotic syndrome (HNKS) in type 2
diabetes. diabetes.
Acute Complications: result from an imbalance in Acute Complications: result from an imbalance in
the treatment regimen.the treatment regimen.
Hypoglycemia (low blood sugar), which is also Hypoglycemia (low blood sugar), which is also
called insulin reaction or insulin shock.called insulin reaction or insulin shock.
Hyperglycemia (high blood sugar), which, if Hyperglycemia (high blood sugar), which, if
uncontrolled, may lead to diabetic ketoacidosis uncontrolled, may lead to diabetic ketoacidosis
(DKA) in type 1 diabetes or hyperosmolar (DKA) in type 1 diabetes or hyperosmolar
nonketotic syndrome (HNKS) in type 2 nonketotic syndrome (HNKS) in type 2
diabetes. diabetes.
Complications of DiabetesComplications of Diabetes
Chronic Complications of type 1 and type 2 diabetes Chronic Complications of type 1 and type 2 diabetes
generally occur 10 to 15 years after the onset of generally occur 10 to 15 years after the onset of
diabetes.diabetes.
Macrovascular (large vessel) disease – affecting coronary Macrovascular (large vessel) disease – affecting coronary
peripheral vascular, and cerebrovascular circulations.peripheral vascular, and cerebrovascular circulations.
Microvascular (small vessel) disease – affecting the eyes Microvascular (small vessel) disease – affecting the eyes
(retinopathy) and kidneys (nephropathy).(retinopathy) and kidneys (nephropathy).
Neuropathic diseases – affecting sensorimotor and Neuropathic diseases – affecting sensorimotor and
autonomic nerves and contributing to such problems aqs autonomic nerves and contributing to such problems aqs
impotence and foot ulcers.impotence and foot ulcers.
Chronic Complications of type 1 and type 2 diabetes Chronic Complications of type 1 and type 2 diabetes
generally occur 10 to 15 years after the onset of generally occur 10 to 15 years after the onset of
diabetes.diabetes.
Macrovascular (large vessel) disease – affecting coronary Macrovascular (large vessel) disease – affecting coronary
peripheral vascular, and cerebrovascular circulations.peripheral vascular, and cerebrovascular circulations.
Microvascular (small vessel) disease – affecting the eyes Microvascular (small vessel) disease – affecting the eyes
(retinopathy) and kidneys (nephropathy).(retinopathy) and kidneys (nephropathy).
Neuropathic diseases – affecting sensorimotor and Neuropathic diseases – affecting sensorimotor and
autonomic nerves and contributing to such problems aqs autonomic nerves and contributing to such problems aqs
impotence and foot ulcers.impotence and foot ulcers.
Learn more about Chronic Learn more about Chronic
Complications of Diabetes Complications of Diabetes
with this video with this video
presentation….presentation….
Complications of Diabetes Complications of Diabetes
with this video with this video
presentation….presentation….
Misconceptions Related to Diabetes and Its Misconceptions Related to Diabetes and Its
TreatmentTreatment
The reason that diabetes The reason that diabetes
develops initially is that there is a develops initially is that there is a
decrease in the amount of insulin decrease in the amount of insulin
in the body or a decrease in the in the body or a decrease in the
ability of insulin to control the ability of insulin to control the
blood glucose level.blood glucose level.
There are several different There are several different
types of sugars (simple types of sugars (simple
carbohydrates) that increase blood carbohydrates) that increase blood
glucose level. Dessert foods often glucose level. Dessert foods often
contain sucrose. Even if the juice contain sucrose. Even if the juice
is labeled “unsweetened”, there is is labeled “unsweetened”, there is
still natural fruit sugar in the still natural fruit sugar in the
product, which causes elevations in product, which causes elevations in
the glucose level.the glucose level.
Diabetes is caused by eating Diabetes is caused by eating
too much sugar.too much sugar.
Sugar is found only in dessert Sugar is found only in dessert
foods.foods.
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
TreatmentTreatment
The reason that diabetes The reason that diabetes
develops initially is that there is a develops initially is that there is a
decrease in the amount of insulin decrease in the amount of insulin
in the body or a decrease in the in the body or a decrease in the
ability of insulin to control the ability of insulin to control the
blood glucose level.blood glucose level.
There are several different There are several different
types of sugars (simple types of sugars (simple
carbohydrates) that increase blood carbohydrates) that increase blood
glucose level. Dessert foods often glucose level. Dessert foods often
contain sucrose. Even if the juice contain sucrose. Even if the juice
is labeled “unsweetened”, there is is labeled “unsweetened”, there is
still natural fruit sugar in the still natural fruit sugar in the
product, which causes elevations in product, which causes elevations in
the glucose level.the glucose level.
Diabetes is caused by eating Diabetes is caused by eating
too much sugar.too much sugar.
Sugar is found only in dessert Sugar is found only in dessert
foods.foods.
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
Misconceptions Related to Diabetes and Its Misconceptions Related to Diabetes and Its
TreatmentTreatment
It is important for the patient It is important for the patient
to realize that it is not feasible to realize that it is not feasible
or advisable to remove all sources or advisable to remove all sources
of sugar from the diet. There are of sugar from the diet. There are
nutritious foods such as fruit that nutritious foods such as fruit that
contain sugar and that should be contain sugar and that should be
included in the meal plan.included in the meal plan.
During period of acute stress During period of acute stress
(such as illness/surgery) or when (such as illness/surgery) or when
receiving certain medications that receiving certain medications that
cause elevations in blood glucose, cause elevations in blood glucose,
some patients with type 2 some patients with type 2
diabetes will require insulin.diabetes will require insulin.
The only diet change needed in The only diet change needed in
the treatment of diabetes is to the treatment of diabetes is to
stop eating sugar.stop eating sugar.
Once insulin injections are Once insulin injections are
started (for treatment of type 2 started (for treatment of type 2
diabetes) they can never be diabetes) they can never be
discontinued.discontinued.
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
TreatmentTreatment
It is important for the patient It is important for the patient
to realize that it is not feasible to realize that it is not feasible
or advisable to remove all sources or advisable to remove all sources
of sugar from the diet. There are of sugar from the diet. There are
nutritious foods such as fruit that nutritious foods such as fruit that
contain sugar and that should be contain sugar and that should be
included in the meal plan.included in the meal plan.
During period of acute stress During period of acute stress
(such as illness/surgery) or when (such as illness/surgery) or when
receiving certain medications that receiving certain medications that
cause elevations in blood glucose, cause elevations in blood glucose,
some patients with type 2 some patients with type 2
diabetes will require insulin.diabetes will require insulin.
The only diet change needed in The only diet change needed in
the treatment of diabetes is to the treatment of diabetes is to
stop eating sugar.stop eating sugar.
Once insulin injections are Once insulin injections are
started (for treatment of type 2 started (for treatment of type 2
diabetes) they can never be diabetes) they can never be
discontinued.discontinued.
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
Misconceptions Related to Diabetes and Its Misconceptions Related to Diabetes and Its
TreatmentTreatment
Explain to the patient that, Explain to the patient that,
unlike other medications that are unlike other medications that are
given in standard doses, there is given in standard doses, there is
not a standard dose of insulin that not a standard dose of insulin that
is effective for all patients. It is is effective for all patients. It is
imp’t to instruct patients that imp’t to instruct patients that
many diff. factors may affect the many diff. factors may affect the
ability of insulin to lower glucose ability of insulin to lower glucose
such as obesity,puberty,illness.such as obesity,puberty,illness.
Explain to patients that there Explain to patients that there
is normally a variation in blood is normally a variation in blood
glucose levels, with the lowest glucose levels, with the lowest
level before meals and the highest level before meals and the highest
1 to 2 hours after eating.1 to 2 hours after eating.
If increasing doses of insulin If increasing doses of insulin
are needed to control the blood are needed to control the blood
glucose, the diabetes must be glucose, the diabetes must be
getting “worse”.getting “worse”.
Blood glucose levels remain the Blood glucose levels remain the
same throughout the day.same throughout the day.
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
TreatmentTreatment
Explain to the patient that, Explain to the patient that,
unlike other medications that are unlike other medications that are
given in standard doses, there is given in standard doses, there is
not a standard dose of insulin that not a standard dose of insulin that
is effective for all patients. It is is effective for all patients. It is
imp’t to instruct patients that imp’t to instruct patients that
many diff. factors may affect the many diff. factors may affect the
ability of insulin to lower glucose ability of insulin to lower glucose
such as obesity,puberty,illness.such as obesity,puberty,illness.
Explain to patients that there Explain to patients that there
is normally a variation in blood is normally a variation in blood
glucose levels, with the lowest glucose levels, with the lowest
level before meals and the highest level before meals and the highest
1 to 2 hours after eating.1 to 2 hours after eating.
If increasing doses of insulin If increasing doses of insulin
are needed to control the blood are needed to control the blood
glucose, the diabetes must be glucose, the diabetes must be
getting “worse”.getting “worse”.
Blood glucose levels remain the Blood glucose levels remain the
same throughout the day.same throughout the day.
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
Misconceptions Related to Diabetes and Its Misconceptions Related to Diabetes and Its
TreatmentTreatment
It must be explained to the It must be explained to the
patient that factors such as patient that factors such as
elevated blood glucose and elevated blood glucose and
elevated blood pressure levels (and elevated blood pressure levels (and
not insulin therapy) contribute to not insulin therapy) contribute to
some of the diabetic some of the diabetic
complications.complications.
Explain to the patient that Explain to the patient that
directly testing the blood is the directly testing the blood is the
most accurate method of most accurate method of
measuring the glucose level. The measuring the glucose level. The
urine glucose test, w/c measures urine glucose test, w/c measures
the amt. of glucose that has the amt. of glucose that has
spilled into the urine since the spilled into the urine since the
bladder last emptied, is only bladder last emptied, is only
indirect way of determining indirect way of determining
glucose level in the blood. glucose level in the blood.
Insulin causes blindness (or Insulin causes blindness (or
other diabetic complications.other diabetic complications.
Urine and blood glucose testing Urine and blood glucose testing
are interchangeable. (they provide are interchangeable. (they provide
the same information)the same information)
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
TreatmentTreatment
It must be explained to the It must be explained to the
patient that factors such as patient that factors such as
elevated blood glucose and elevated blood glucose and
elevated blood pressure levels (and elevated blood pressure levels (and
not insulin therapy) contribute to not insulin therapy) contribute to
some of the diabetic some of the diabetic
complications.complications.
Explain to the patient that Explain to the patient that
directly testing the blood is the directly testing the blood is the
most accurate method of most accurate method of
measuring the glucose level. The measuring the glucose level. The
urine glucose test, w/c measures urine glucose test, w/c measures
the amt. of glucose that has the amt. of glucose that has
spilled into the urine since the spilled into the urine since the
bladder last emptied, is only bladder last emptied, is only
indirect way of determining indirect way of determining
glucose level in the blood. glucose level in the blood.
Insulin causes blindness (or Insulin causes blindness (or
other diabetic complications.other diabetic complications.
Urine and blood glucose testing Urine and blood glucose testing
are interchangeable. (they provide are interchangeable. (they provide
the same information)the same information)
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
Misconceptions Related to Diabetes and Its Misconceptions Related to Diabetes and Its
TreatmentTreatment
The patient must be reassured The patient must be reassured
that insulin is injected into the fat that insulin is injected into the fat
tissue on the back of the arm (or tissue on the back of the arm (or
on the abdomen, thigh, or hip) and on the abdomen, thigh, or hip) and
that the needle is much shorter that the needle is much shorter
than that used for venipuncture.than that used for venipuncture.
This maybe related to This maybe related to
misconception that insulin is misconception that insulin is
injected directly to the vein. injected directly to the vein.
Reassure patients that the main Reassure patients that the main
danger in having air bubbles in the danger in having air bubbles in the
insulin syringe is that the amount of insulin syringe is that the amount of
insulin being injected is less than insulin being injected is less than
the required dosage.the required dosage.
Insulin must be injected Insulin must be injected
directly into the vein.directly into the vein.
There is extreme danger in There is extreme danger in
injecting insulin if there are any injecting insulin if there are any
air bubbles in the syringe.air bubbles in the syringe.
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
TreatmentTreatment
The patient must be reassured The patient must be reassured
that insulin is injected into the fat that insulin is injected into the fat
tissue on the back of the arm (or tissue on the back of the arm (or
on the abdomen, thigh, or hip) and on the abdomen, thigh, or hip) and
that the needle is much shorter that the needle is much shorter
than that used for venipuncture.than that used for venipuncture.
This maybe related to This maybe related to
misconception that insulin is misconception that insulin is
injected directly to the vein. injected directly to the vein.
Reassure patients that the main Reassure patients that the main
danger in having air bubbles in the danger in having air bubbles in the
insulin syringe is that the amount of insulin syringe is that the amount of
insulin being injected is less than insulin being injected is less than
the required dosage.the required dosage.
Insulin must be injected Insulin must be injected
directly into the vein.directly into the vein.
There is extreme danger in There is extreme danger in
injecting insulin if there are any injecting insulin if there are any
air bubbles in the syringe.air bubbles in the syringe.
Nurse’s ResponseNurse’s ResponseMisconceptionMisconception
Morning HyperglycemiaMorning Hyperglycemia
•Insulin WaningInsulin Waning – Progressive rise in blood glucose from – Progressive rise in blood glucose from
bedtime to morning. bedtime to morning. TTTT: Increase evening dose of : Increase evening dose of
intermediate or long acting insulin.intermediate or long acting insulin.
•Dawn PhenomenonDawn Phenomenon – Relatively normal blood glucose until – Relatively normal blood glucose until
about 3am when the level begins to rise. about 3am when the level begins to rise. TTTT: Change : Change
time of injection of evening intermediate acting insulin time of injection of evening intermediate acting insulin
from dinner time to bedtime.from dinner time to bedtime.
•Somogyi EffectSomogyi Effect – Normal or elevated glucose at – Normal or elevated glucose at
bedtime, a decrease at 2-3am to hypoglycemic levels, bedtime, a decrease at 2-3am to hypoglycemic levels,
and a subsequent increase caused by the production of and a subsequent increase caused by the production of
counter regulatory hormones. counter regulatory hormones. TTTT: Decrease dose of : Decrease dose of
evening intermediate acting insulin or increase evening evening intermediate acting insulin or increase evening
snack.snack.
•Insulin WaningInsulin Waning – Progressive rise in blood glucose from – Progressive rise in blood glucose from
bedtime to morning. bedtime to morning. TTTT: Increase evening dose of : Increase evening dose of
intermediate or long acting insulin.intermediate or long acting insulin.
•Dawn PhenomenonDawn Phenomenon – Relatively normal blood glucose until – Relatively normal blood glucose until
about 3am when the level begins to rise. about 3am when the level begins to rise. TTTT: Change : Change
time of injection of evening intermediate acting insulin time of injection of evening intermediate acting insulin
from dinner time to bedtime.from dinner time to bedtime.
•Somogyi EffectSomogyi Effect – Normal or elevated glucose at – Normal or elevated glucose at
bedtime, a decrease at 2-3am to hypoglycemic levels, bedtime, a decrease at 2-3am to hypoglycemic levels,
and a subsequent increase caused by the production of and a subsequent increase caused by the production of
counter regulatory hormones. counter regulatory hormones. TTTT: Decrease dose of : Decrease dose of
evening intermediate acting insulin or increase evening evening intermediate acting insulin or increase evening
snack.snack.
Foot and Leg Problems in DiabetesFoot and Leg Problems in Diabetes
55% to 75% of lower extremity amputations are performed 55% to 75% of lower extremity amputations are performed
on people with Diabetes. 50% of these amputations are on people with Diabetes. 50% of these amputations are
preventable, provided patients are taught preventive preventable, provided patients are taught preventive
foot care measures and practice preventive foot care on foot care measures and practice preventive foot care on
a daily basis.a daily basis.
Three diabetic complications contribute to the increased Three diabetic complications contribute to the increased
risk of foot infections. They are:risk of foot infections. They are:
A. NeuropathyA. Neuropathy – Sensory neuropathy leads to loss of pain – Sensory neuropathy leads to loss of pain
and pressure sensation, and autonomic neuropathy leads and pressure sensation, and autonomic neuropathy leads
to increased dryness and fissuring of the skin (secondary to increased dryness and fissuring of the skin (secondary
to decreased sweating).to decreased sweating).
55% to 75% of lower extremity amputations are performed 55% to 75% of lower extremity amputations are performed
on people with Diabetes. 50% of these amputations are on people with Diabetes. 50% of these amputations are
preventable, provided patients are taught preventive preventable, provided patients are taught preventive
foot care measures and practice preventive foot care on foot care measures and practice preventive foot care on
a daily basis.a daily basis.
Three diabetic complications contribute to the increased Three diabetic complications contribute to the increased
risk of foot infections. They are:risk of foot infections. They are:
A. NeuropathyA. Neuropathy – Sensory neuropathy leads to loss of pain – Sensory neuropathy leads to loss of pain
and pressure sensation, and autonomic neuropathy leads and pressure sensation, and autonomic neuropathy leads
to increased dryness and fissuring of the skin (secondary to increased dryness and fissuring of the skin (secondary
to decreased sweating).to decreased sweating).
Foot and Leg Problems in DiabetesFoot and Leg Problems in Diabetes
B. Peripheral vascular diseaseB. Peripheral vascular disease – Poor circulation of the lower – Poor circulation of the lower
extremities contributes to poor wound healing and the extremities contributes to poor wound healing and the
development of gangrene.development of gangrene.
C. ImmunocompromiseC. Immunocompromise – Hyperglycemia impairs the ability of – Hyperglycemia impairs the ability of
specialized leukocytes to destroy bacteria. Thus, in poorly specialized leukocytes to destroy bacteria. Thus, in poorly
controlled diabetes there is a lowered resistance to controlled diabetes there is a lowered resistance to
certain infections.certain infections.
Diabetic foot ulcer begins with a soft tissue injury of the Diabetic foot ulcer begins with a soft tissue injury of the
foot, the injury or fissure may go unnoticed until a serious foot, the injury or fissure may go unnoticed until a serious
infection has developed. Drainage, swelling, redness (from infection has developed. Drainage, swelling, redness (from
cellulitis) of the leg, or gangrene may be the first sign of cellulitis) of the leg, or gangrene may be the first sign of
foot problems that the patient notices foot problems that the patient notices
B. Peripheral vascular diseaseB. Peripheral vascular disease – Poor circulation of the lower – Poor circulation of the lower
extremities contributes to poor wound healing and the extremities contributes to poor wound healing and the
development of gangrene.development of gangrene.
C. ImmunocompromiseC. Immunocompromise – Hyperglycemia impairs the ability of – Hyperglycemia impairs the ability of
specialized leukocytes to destroy bacteria. Thus, in poorly specialized leukocytes to destroy bacteria. Thus, in poorly
controlled diabetes there is a lowered resistance to controlled diabetes there is a lowered resistance to
certain infections.certain infections.
Diabetic foot ulcer begins with a soft tissue injury of the Diabetic foot ulcer begins with a soft tissue injury of the
foot, the injury or fissure may go unnoticed until a serious foot, the injury or fissure may go unnoticed until a serious
infection has developed. Drainage, swelling, redness (from infection has developed. Drainage, swelling, redness (from
cellulitis) of the leg, or gangrene may be the first sign of cellulitis) of the leg, or gangrene may be the first sign of
foot problems that the patient notices foot problems that the patient notices
Foot and Leg Problems in DiabetesFoot and Leg Problems in Diabetes
Treatment of foot ulcers involves bed rest, antibiotics, and Treatment of foot ulcers involves bed rest, antibiotics, and
debridement.debridement.
In peripheral vascular diseases, foot ulcers may not heal In peripheral vascular diseases, foot ulcers may not heal
because of the decreased ability of oxygen, nutrients, and because of the decreased ability of oxygen, nutrients, and
antibotics to reach the injured tissue. Amputation may be antibotics to reach the injured tissue. Amputation may be
necessary to prevent further spread of infection.necessary to prevent further spread of infection.
Foot Assessment and Foot Care instruction are most important in Foot Assessment and Foot Care instruction are most important in
dealing with patient who are high risk of developing foot dealing with patient who are high risk of developing foot
ulcers.ulcers.
•Duration of diabetes over 10 yearsDuration of diabetes over 10 years
•Age over 40 yearsAge over 40 years
•History of smokingHistory of smoking
•Decreased peripheral pulsesDecreased peripheral pulses
•Decreased sensationDecreased sensation
•Anatomic deformities or pressure areas (such as calluses)Anatomic deformities or pressure areas (such as calluses)
•History of previous foot ulcers or amputation History of previous foot ulcers or amputation
Treatment of foot ulcers involves bed rest, antibiotics, and Treatment of foot ulcers involves bed rest, antibiotics, and
debridement.debridement.
In peripheral vascular diseases, foot ulcers may not heal In peripheral vascular diseases, foot ulcers may not heal
because of the decreased ability of oxygen, nutrients, and because of the decreased ability of oxygen, nutrients, and
antibotics to reach the injured tissue. Amputation may be antibotics to reach the injured tissue. Amputation may be
necessary to prevent further spread of infection.necessary to prevent further spread of infection.
Foot Assessment and Foot Care instruction are most important in Foot Assessment and Foot Care instruction are most important in
dealing with patient who are high risk of developing foot dealing with patient who are high risk of developing foot
ulcers.ulcers.
•Duration of diabetes over 10 yearsDuration of diabetes over 10 years
•Age over 40 yearsAge over 40 years
•History of smokingHistory of smoking
•Decreased peripheral pulsesDecreased peripheral pulses
•Decreased sensationDecreased sensation
•Anatomic deformities or pressure areas (such as calluses)Anatomic deformities or pressure areas (such as calluses)
•History of previous foot ulcers or amputation History of previous foot ulcers or amputation
Foot Care….Foot Care….
Preventive foot care includes properly bathing, Preventive foot care includes properly bathing,
drying, and lubricating feet (care must be taken drying, and lubricating feet (care must be taken
not to allow moisture to accumulate from water or not to allow moisture to accumulate from water or
lotion between the toes.)lotion between the toes.)
Feet must be inspected on a daily basis for any Feet must be inspected on a daily basis for any
redness, blisters, fissures, calluses or ulcerations.redness, blisters, fissures, calluses or ulcerations.
The interior surface of the shoes should be The interior surface of the shoes should be
inspected for any rough spots or foreign objects.inspected for any rough spots or foreign objects.
Feet should be examined on a regular basis by a Feet should be examined on a regular basis by a
podiatrist, physician, or nurse.podiatrist, physician, or nurse.
Preventive foot care includes properly bathing, Preventive foot care includes properly bathing,
drying, and lubricating feet (care must be taken drying, and lubricating feet (care must be taken
not to allow moisture to accumulate from water or not to allow moisture to accumulate from water or
lotion between the toes.)lotion between the toes.)
Feet must be inspected on a daily basis for any Feet must be inspected on a daily basis for any
redness, blisters, fissures, calluses or ulcerations.redness, blisters, fissures, calluses or ulcerations.
The interior surface of the shoes should be The interior surface of the shoes should be
inspected for any rough spots or foreign objects.inspected for any rough spots or foreign objects.
Feet should be examined on a regular basis by a Feet should be examined on a regular basis by a
podiatrist, physician, or nurse.podiatrist, physician, or nurse.
Foot Care….Foot Care….
Patients with thick toenails should see the Patients with thick toenails should see the
podiatrist routinely for shaving of calluses and podiatrist routinely for shaving of calluses and
trimming of nails.trimming of nails.
Patients should be taught to wear well-fitting, Patients should be taught to wear well-fitting,
closed toe shoes.closed toe shoes.
High risk behaviors should be avoided, such as High risk behaviors should be avoided, such as
walking barefoot, using heating pads on the feet, walking barefoot, using heating pads on the feet,
wearing open toed shoes, and shaving calluses.wearing open toed shoes, and shaving calluses.
Toenails should be trimmed straight across Toenails should be trimmed straight across
without rounding the corners.without rounding the corners.
Patients with thick toenails should see the Patients with thick toenails should see the
podiatrist routinely for shaving of calluses and podiatrist routinely for shaving of calluses and
trimming of nails.trimming of nails.
Patients should be taught to wear well-fitting, Patients should be taught to wear well-fitting,
closed toe shoes.closed toe shoes.
High risk behaviors should be avoided, such as High risk behaviors should be avoided, such as
walking barefoot, using heating pads on the feet, walking barefoot, using heating pads on the feet,
wearing open toed shoes, and shaving calluses.wearing open toed shoes, and shaving calluses.
Toenails should be trimmed straight across Toenails should be trimmed straight across
without rounding the corners.without rounding the corners.
Types (Levels) of AmputationsTypes (Levels) of Amputations
Amputations can be divided into two types: minor and Amputations can be divided into two types: minor and
major. major.
Minor or limited amputationsMinor or limited amputations are amputations where only a are amputations where only a
toe or part of the foot is removed.toe or part of the foot is removed.
A A ray amputationray amputation is a particular form of minor amputation is a particular form of minor amputation
where a toe and part of the corresponding metatarsal where a toe and part of the corresponding metatarsal
bone is removed; and the wound is usually left open to bone is removed; and the wound is usually left open to
heal. This sort of operation is performed frequently for heal. This sort of operation is performed frequently for
foot infections in patients with diabetes. A partial foot foot infections in patients with diabetes. A partial foot
amputation through the metatarsal bones is called amputation through the metatarsal bones is called
transmetatarsal (TM) amputation.transmetatarsal (TM) amputation.
Amputations can be divided into two types: minor and Amputations can be divided into two types: minor and
major. major.
Minor or limited amputationsMinor or limited amputations are amputations where only a are amputations where only a
toe or part of the foot is removed.toe or part of the foot is removed.
A A ray amputationray amputation is a particular form of minor amputation is a particular form of minor amputation
where a toe and part of the corresponding metatarsal where a toe and part of the corresponding metatarsal
bone is removed; and the wound is usually left open to bone is removed; and the wound is usually left open to
heal. This sort of operation is performed frequently for heal. This sort of operation is performed frequently for
foot infections in patients with diabetes. A partial foot foot infections in patients with diabetes. A partial foot
amputation through the metatarsal bones is called amputation through the metatarsal bones is called
transmetatarsal (TM) amputation.transmetatarsal (TM) amputation.
A Gangrene Foot….A Gangrene Foot….
Transmetatarsal (TM) amputationTransmetatarsal (TM) amputation
Types (Levels) of AmputationsTypes (Levels) of Amputations
Major amputations are amputations where part of the leg is Major amputations are amputations where part of the leg is
removed. removed.
These are usually: These are usually:
•below the knee, called below the knee, called transtibial (TT) amputation, or transtibial (TT) amputation, or
•above the knee, called above the knee, called transfemoral (TF) amputation.transfemoral (TF) amputation.
Occasionally an amputation of just the foot can be Occasionally an amputation of just the foot can be
performed with a cut through the ankle joint. performed with a cut through the ankle joint.
Below the knee operation (transtibial amuptation), the bone Below the knee operation (transtibial amuptation), the bone
in the lower leg (tibia) is divided about 12-15 cm below in the lower leg (tibia) is divided about 12-15 cm below
the knee joint. This produces a good size stump to which the knee joint. This produces a good size stump to which
a prosthesis can be fitted. a prosthesis can be fitted.
Major amputations are amputations where part of the leg is Major amputations are amputations where part of the leg is
removed. removed.
These are usually: These are usually:
•below the knee, called below the knee, called transtibial (TT) amputation, or transtibial (TT) amputation, or
•above the knee, called above the knee, called transfemoral (TF) amputation.transfemoral (TF) amputation.
Occasionally an amputation of just the foot can be Occasionally an amputation of just the foot can be
performed with a cut through the ankle joint. performed with a cut through the ankle joint.
Below the knee operation (transtibial amuptation), the bone Below the knee operation (transtibial amuptation), the bone
in the lower leg (tibia) is divided about 12-15 cm below in the lower leg (tibia) is divided about 12-15 cm below
the knee joint. This produces a good size stump to which the knee joint. This produces a good size stump to which
a prosthesis can be fitted. a prosthesis can be fitted.
BELOW KNEE AMPUTATION DUE TO ISCHEMIA BELOW KNEE AMPUTATION DUE TO ISCHEMIA
NECROSISNECROSIS
NECROSISNECROSIS
Learn more about Diabetic Learn more about Diabetic
Foot Care with this video Foot Care with this video
presentation….presentation….
Foot Care with this video Foot Care with this video
presentation….presentation….
What can you do to control your What can you do to control your
blood sugar?blood sugar?
1. Diet Therapy 1. Diet Therapy
* Avoid simple sugars like cakes and * Avoid simple sugars like cakes and
chocolates. Instead have complex chocolates. Instead have complex
carbohydrated like rice, pasta, cereals and carbohydrated like rice, pasta, cereals and
fresh fruits.fresh fruits.
* Do not skip or delay meals. It causes * Do not skip or delay meals. It causes
fluctuations in blood sugar levels.fluctuations in blood sugar levels.
* Eat more fiber-rich foods like vegetables.* Eat more fiber-rich foods like vegetables.
* Cut down on salt.* Cut down on salt.
* Avoid alcohol. Dietary guidelines recommend * Avoid alcohol. Dietary guidelines recommend
no more than two drinks for men and no more no more than two drinks for men and no more
than one drink per day for women.than one drink per day for women.
blood sugar?blood sugar?
1. Diet Therapy 1. Diet Therapy
* Avoid simple sugars like cakes and * Avoid simple sugars like cakes and
chocolates. Instead have complex chocolates. Instead have complex
carbohydrated like rice, pasta, cereals and carbohydrated like rice, pasta, cereals and
fresh fruits.fresh fruits.
* Do not skip or delay meals. It causes * Do not skip or delay meals. It causes
fluctuations in blood sugar levels.fluctuations in blood sugar levels.
* Eat more fiber-rich foods like vegetables.* Eat more fiber-rich foods like vegetables.
* Cut down on salt.* Cut down on salt.
* Avoid alcohol. Dietary guidelines recommend * Avoid alcohol. Dietary guidelines recommend
no more than two drinks for men and no more no more than two drinks for men and no more
than one drink per day for women.than one drink per day for women.
2. Exercise2. Exercise
Regular exercise is an important part of diabetes Regular exercise is an important part of diabetes
control.control.
Daily exercise . . .Daily exercise . . .
* Improves cardiovascular fitness* Improves cardiovascular fitness
* Helps insulin to work better and lower blood sugar* Helps insulin to work better and lower blood sugar
* Lowers blood pressure and cholesterol levels* Lowers blood pressure and cholesterol levels
* Reduces body fat and controls body weight* Reduces body fat and controls body weight
Exercise at least 3 time a week for ate least 30 minutes Exercise at least 3 time a week for ate least 30 minutes
each session. Always carry quick sugar sources like candy each session. Always carry quick sugar sources like candy
or softdrink to avoid hypoglycemia (low blood sugar) or softdrink to avoid hypoglycemia (low blood sugar)
during and after exercise.during and after exercise.
Regular exercise is an important part of diabetes Regular exercise is an important part of diabetes
control.control.
Daily exercise . . .Daily exercise . . .
* Improves cardiovascular fitness* Improves cardiovascular fitness
* Helps insulin to work better and lower blood sugar* Helps insulin to work better and lower blood sugar
* Lowers blood pressure and cholesterol levels* Lowers blood pressure and cholesterol levels
* Reduces body fat and controls body weight* Reduces body fat and controls body weight
Exercise at least 3 time a week for ate least 30 minutes Exercise at least 3 time a week for ate least 30 minutes
each session. Always carry quick sugar sources like candy each session. Always carry quick sugar sources like candy
or softdrink to avoid hypoglycemia (low blood sugar) or softdrink to avoid hypoglycemia (low blood sugar)
during and after exercise.during and after exercise.
3. Control your weight 3. Control your weight
If you are overweight or obese, start weight If you are overweight or obese, start weight
reduction by diet and exercise. This improves reduction by diet and exercise. This improves
your cardiovascular risk profile.your cardiovascular risk profile.
* It lowers your blood sugar* It lowers your blood sugar
* It improves your lipid profile* It improves your lipid profile
* It improves your blood pressure control* It improves your blood pressure control
4. Quit smoking.4. Quit smoking.
Smoking is harmful to your health.Smoking is harmful to your health.
If you are overweight or obese, start weight If you are overweight or obese, start weight
reduction by diet and exercise. This improves reduction by diet and exercise. This improves
your cardiovascular risk profile.your cardiovascular risk profile.
* It lowers your blood sugar* It lowers your blood sugar
* It improves your lipid profile* It improves your lipid profile
* It improves your blood pressure control* It improves your blood pressure control
4. Quit smoking.4. Quit smoking.
Smoking is harmful to your health.Smoking is harmful to your health.
5. Maintain a normal blood 5. Maintain a normal blood
pressure.pressure.
Since having hypertension puts a Since having hypertension puts a
person at high risk of person at high risk of
cardiovascular disease, especially cardiovascular disease, especially
if it is associated with diabetes, if it is associated with diabetes,
reliable BP monitoring and control reliable BP monitoring and control
is recommended.is recommended.
pressure.pressure.
Since having hypertension puts a Since having hypertension puts a
person at high risk of person at high risk of
cardiovascular disease, especially cardiovascular disease, especially
if it is associated with diabetes, if it is associated with diabetes,
reliable BP monitoring and control reliable BP monitoring and control
is recommended.is recommended.
There are drug therapies using oral hypoglycemic There are drug therapies using oral hypoglycemic
agents. Your doctor can prescribe one or two agent, agents. Your doctor can prescribe one or two agent,
depending on which is appropriate for you.depending on which is appropriate for you.
1. Sulfonylurea – Glibenclamide, Gliclazide, 1. Sulfonylurea – Glibenclamide, Gliclazide,
Glipizide, Glimepiride, RepaglinideGlipizide, Glimepiride, Repaglinide
2. Biguanide – Metformin2. Biguanide – Metformin
3. Alpha-glucosidase Inhibitors – Acarbose3. Alpha-glucosidase Inhibitors – Acarbose
4. Thiazolidindione – Troglitazone, Rosiglitazone, 4. Thiazolidindione – Troglitazone, Rosiglitazone,
Proglitazone. Proglitazone.
agents. Your doctor can prescribe one or two agent, agents. Your doctor can prescribe one or two agent,
depending on which is appropriate for you.depending on which is appropriate for you.
1. Sulfonylurea – Glibenclamide, Gliclazide, 1. Sulfonylurea – Glibenclamide, Gliclazide,
Glipizide, Glimepiride, RepaglinideGlipizide, Glimepiride, Repaglinide
2. Biguanide – Metformin2. Biguanide – Metformin
3. Alpha-glucosidase Inhibitors – Acarbose3. Alpha-glucosidase Inhibitors – Acarbose
4. Thiazolidindione – Troglitazone, Rosiglitazone, 4. Thiazolidindione – Troglitazone, Rosiglitazone,
Proglitazone. Proglitazone.
Insulin Therapy….Insulin Therapy….
Insulin preparation vary according to four main characteristics: time course Insulin preparation vary according to four main characteristics: time course
of action, concentration, species (source), and manufacturer.of action, concentration, species (source), and manufacturer.
Time course Time course – Insulin may be grouped into 3 main categories based – Insulin may be grouped into 3 main categories based
on onset, peak, duration of action.on onset, peak, duration of action.
Concentration Concentration – Most common concentration of insulin in the united – Most common concentration of insulin in the united
states is U-100. Means that there are 100 units of insulin per states is U-100. Means that there are 100 units of insulin per
1 cubic centimeter. 100 units of U-100 is 1 ml, 50 units of 1 cubic centimeter. 100 units of U-100 is 1 ml, 50 units of
U-100 is 1/2ml. U-100 is 1/2ml.
Species Species – Derived from pancreas of cows and pigs and conversion of – Derived from pancreas of cows and pigs and conversion of
this insulin to human insulin. this insulin to human insulin.
Manufacturer Manufacturer – Lilly human insulin – “Humulin” and Novo Nordisk – Lilly human insulin – “Humulin” and Novo Nordisk
human insulin – “Novolin”human insulin – “Novolin”
Insulin preparation vary according to four main characteristics: time course Insulin preparation vary according to four main characteristics: time course
of action, concentration, species (source), and manufacturer.of action, concentration, species (source), and manufacturer.
Time course Time course – Insulin may be grouped into 3 main categories based – Insulin may be grouped into 3 main categories based
on onset, peak, duration of action.on onset, peak, duration of action.
Concentration Concentration – Most common concentration of insulin in the united – Most common concentration of insulin in the united
states is U-100. Means that there are 100 units of insulin per states is U-100. Means that there are 100 units of insulin per
1 cubic centimeter. 100 units of U-100 is 1 ml, 50 units of 1 cubic centimeter. 100 units of U-100 is 1 ml, 50 units of
U-100 is 1/2ml. U-100 is 1/2ml.
Species Species – Derived from pancreas of cows and pigs and conversion of – Derived from pancreas of cows and pigs and conversion of
this insulin to human insulin. this insulin to human insulin.
Manufacturer Manufacturer – Lilly human insulin – “Humulin” and Novo Nordisk – Lilly human insulin – “Humulin” and Novo Nordisk
human insulin – “Novolin”human insulin – “Novolin”
Insulin Therapy….Insulin Therapy….
CloudyCloudy30 to 36 30 to 36
hours or hours or
greatergreater
14 to 20 14 to 20
hourshours
6 to 8 hours6 to 8 hours
Long acting Long acting
insulininsulin
• UltralenteUltralente
CloudyCloudy
CloudyCloudy
20 to 24 20 to 24
hourshours
SameSame
8 to 16 hours8 to 16 hours
SameSame
3 to 4 hours3 to 4 hours
SameSame
Intermediate Intermediate
acting insulinacting insulin
• NPHNPH
• LenteLente
ClearClear
ClearClear
6 to 8 hours6 to 8 hours
8 to 12 hours8 to 12 hours
2 to 4 hours2 to 4 hours
4 to 6 hours4 to 6 hours
½ to 1 hour½ to 1 hour
1 to 2 hours1 to 2 hours
Short acting Short acting
insulininsulin
• RegularRegular
•SemilenteSemilente
CONSISTENCYCONSISTENCYDURATIONDURATIONPEAKPEAKONSETONSET
CloudyCloudy30 to 36 30 to 36
hours or hours or
greatergreater
14 to 20 14 to 20
hourshours
6 to 8 hours6 to 8 hours
Long acting Long acting
insulininsulin
• UltralenteUltralente
CloudyCloudy
CloudyCloudy
20 to 24 20 to 24
hourshours
SameSame
8 to 16 hours8 to 16 hours
SameSame
3 to 4 hours3 to 4 hours
SameSame
Intermediate Intermediate
acting insulinacting insulin
• NPHNPH
• LenteLente
ClearClear
ClearClear
6 to 8 hours6 to 8 hours
8 to 12 hours8 to 12 hours
2 to 4 hours2 to 4 hours
4 to 6 hours4 to 6 hours
½ to 1 hour½ to 1 hour
1 to 2 hours1 to 2 hours
Short acting Short acting
insulininsulin
• RegularRegular
•SemilenteSemilente
CONSISTENCYCONSISTENCYDURATIONDURATIONPEAKPEAKONSETONSET
Learn more about Insulin Learn more about Insulin
Preparation and Injecting Preparation and Injecting
Insulin with this video Insulin with this video
presentation….presentation….
Preparation and Injecting Preparation and Injecting
Insulin with this video Insulin with this video
presentation….presentation….
RememberRemember
If you have the classic symptoms of diabetes:If you have the classic symptoms of diabetes:
* See your doctor for blood sugar testing* See your doctor for blood sugar testing
* Start dieting* Start dieting
* Eat plenty of vegetables* Eat plenty of vegetables
* Avoid sweets such as chocolates and cakes* Avoid sweets such as chocolates and cakes
* Cut down on fatty foods* Cut down on fatty foods
* Exercise regularly* Exercise regularly
* If you are obese, try to lose some weight* If you are obese, try to lose some weight
* Avoid alcohol drinking and stop smoking* Avoid alcohol drinking and stop smoking
* If you are hypertensive, consult your doctor * If you are hypertensive, consult your doctor
for advice and managementfor advice and management
If you have the classic symptoms of diabetes:If you have the classic symptoms of diabetes:
* See your doctor for blood sugar testing* See your doctor for blood sugar testing
* Start dieting* Start dieting
* Eat plenty of vegetables* Eat plenty of vegetables
* Avoid sweets such as chocolates and cakes* Avoid sweets such as chocolates and cakes
* Cut down on fatty foods* Cut down on fatty foods
* Exercise regularly* Exercise regularly
* If you are obese, try to lose some weight* If you are obese, try to lose some weight
* Avoid alcohol drinking and stop smoking* Avoid alcohol drinking and stop smoking
* If you are hypertensive, consult your doctor * If you are hypertensive, consult your doctor
for advice and managementfor advice and management
DOH Calendar of EventsDOH Calendar of Events
July 2008July 2008
> National Blood Donors Month> National Blood Donors Month
> Nutrition Month> Nutrition Month
> National Disaster Consciousness Week (1-7)> National Disaster Consciousness Week (1-7)
> World Population Day (11)> World Population Day (11)
> National Disability Prevention and > National Disability Prevention and
Rehabilitation Week (14-20)Rehabilitation Week (14-20)
> National Diabetes Awareness Week (14-20)> National Diabetes Awareness Week (14-20)
July 2008July 2008
> National Blood Donors Month> National Blood Donors Month
> Nutrition Month> Nutrition Month
> National Disaster Consciousness Week (1-7)> National Disaster Consciousness Week (1-7)
> World Population Day (11)> World Population Day (11)
> National Disability Prevention and > National Disability Prevention and
Rehabilitation Week (14-20)Rehabilitation Week (14-20)
> National Diabetes Awareness Week (14-20)> National Diabetes Awareness Week (14-20)
DOH Calendar of EventsDOH Calendar of Events
November 2008November 2008
> Cancer Pain Awareness Month> Cancer Pain Awareness Month
> Filariasis Awareness Month> Filariasis Awareness Month
> Malaria Awareness Month> Malaria Awareness Month
> Traditional and Alternative Health Care Month> Traditional and Alternative Health Care Month
> Chronic Obstructive Pulmonary Disease (COPD) > Chronic Obstructive Pulmonary Disease (COPD)
Awareness Week (3-9) Awareness Week (3-9)
> National Skin Disease Detection and Prevention Week > National Skin Disease Detection and Prevention Week
(10-16)(10-16)
> National Food Fortification Day (7)> National Food Fortification Day (7)
> Deaf Awareness Week (10-16)> Deaf Awareness Week (10-16)
> World Diabetes Day (14)> World Diabetes Day (14)
> Drug Abuse Prevention and Control Week (17-23)> Drug Abuse Prevention and Control Week (17-23)
> Population and Development Week (23-29)> Population and Development Week (23-29)
November 2008November 2008
> Cancer Pain Awareness Month> Cancer Pain Awareness Month
> Filariasis Awareness Month> Filariasis Awareness Month
> Malaria Awareness Month> Malaria Awareness Month
> Traditional and Alternative Health Care Month> Traditional and Alternative Health Care Month
> Chronic Obstructive Pulmonary Disease (COPD) > Chronic Obstructive Pulmonary Disease (COPD)
Awareness Week (3-9) Awareness Week (3-9)
> National Skin Disease Detection and Prevention Week > National Skin Disease Detection and Prevention Week
(10-16)(10-16)
> National Food Fortification Day (7)> National Food Fortification Day (7)
> Deaf Awareness Week (10-16)> Deaf Awareness Week (10-16)
> World Diabetes Day (14)> World Diabetes Day (14)
> Drug Abuse Prevention and Control Week (17-23)> Drug Abuse Prevention and Control Week (17-23)
> Population and Development Week (23-29)> Population and Development Week (23-29)
Doctor’s View about Diabetes Doctor’s View about Diabetes
Mellitus 1 & 2 thru video Mellitus 1 & 2 thru video
presentations….presentations….
Mellitus 1 & 2 thru video Mellitus 1 & 2 thru video
presentations….presentations….
THANK THANK
YOU YOU
VERY VERY
MUCHMUCH
FOR FOR
WATCHING WATCHING
AND AND
LISTENINGLISTENING
YOU YOU
VERY VERY
MUCHMUCH
FOR FOR
WATCHING WATCHING
AND AND
LISTENINGLISTENING
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